Management Of Genital Prolapse Associate Professor Semyatov S.M. Department of Obstetrics and Gynecology with course Perinatology Peoples’ Friendship University of Russia, Moscow
DEFINITION Prolapse/Procidentia is downward decent of uterus &/or vagina. (Procidentia is from Latin procidere - to fall). It is a state of pelvic relaxation due to a disorder of pelvic support structures that is, the endopelvic fascia. It is not a disease but a disabling condition.
CAUSE WEAKNESS OF THE SUPPORTS OF THE UTERUS & VAGINA Precipitating / Exaggerating / Unmasking Causes - INCREASED INTRA ABDOMINAL PRESSURE Heavy Wt.Lifting / domestic Work WEAKNESS OF THE SUPPORTS & MUSCLES Chronic ill health, malnutrition dysentery, anemia
Inadequate rest during pureperium
TYPES OF PROLAPSE Anterior –cystocele & urethrocele Posterior - Enterocele & Rectocele Vault Prolapse - a special term applied to the prolapse of upper vagina Uterine/Utero-vaginal- Acquired or Congenital. Third degree-(total Prolapse / complete procidentia).
However Procidentia is often used only to denote third degree uterine prolapse.
EFFECTS OF PROLAPSE NO SYMPTOM- mild & moderate prolapse. URINARY- Frequency, Dysuria, Stress incontinence, infection.
Incomplete emptying of rectum.
WHEN TO TREAT ? Should be treated only when it is symptomatic (Be certain symptoms are due to Prolapse ) Interferes with the normal activity of the woman
The patient seeks treatment
HOW TO TREAT ? NON-SURGICAL Methods: -Limited Role PELVIC FLOOR REHABILITATION (pelvic muscle exercises, galvanic stimulation, physiotherapy, rest in the purperium). HORMONE REPLACEMENT, both systemic and local. PESSARY TREATMENT for temporary relief During Pregnancy, Puerperium & Lactation
When Operation is Unsafe due to Extreme Senility/Debility and Diseases
HOW TO TREAT ?
SURGICAL TREATMENT: - RECONSTRUCTIVE SURGERY is invariably needed and has to be a COMBINATION OF PROCEDURES to correct the multiple defects.
SURGICAL TREATMENT It is the definitive & curative treatment of Prolapse. It is a cold operation. So complete investigation should be done & all existing diseases & disorders should be treated first. Pre operative pessary/tampoon & or Hormone treatment should be given as indicated.
Meticulous and through examination under anaesthesia should be done before deciding the surgery.
SURGICAL TREATMENT Depending on the type & extent of Prolapse, surgery should be tailor made not only to rectify the defect but also to suit the individual patient’s requirement. Absolute haemostasis is mandatory. Diathermy should be liberally used. Vaginal suturing should be with interrupted stitches. Synthetic absorbable fine sutures are preferable. Catheter for more than 48 hrs should be exceptional.
Strict antibiotic prophylaxis is essential
VAGINAL OPERATIONS FOR PROLAPSE Posterior colporrhapry- High / Low
Hysterectomy with or without Colporrhaphy / Perineorrhaphy
VAGINAL OPERATIONS FOR PROLAPSE Manchester/ Fothergill’s operation & Shirodkar’s modification Uterus/Cervix suspension/fixation Vaginal vault suspension/fixation
Retro-rectal levatorplasty and post. anal repair for associated rectal prolapse
Anterior colporrhaphy & Urethroplasty For correction of Cystocele & Urethrocele Incision- Midline / Inv.T / Elliptical Excision of vagina according to the size & site of laxity Avoid shortening &/or narrowing of vagina
Closure with interrupted sutures
Posterior colporrhaphy & Enterocele repair For correction of Enterocele & Rectocele Enterocele repair can be done either by vaginal or abdominal route depending on the associated procedures. Approximation of uterosacral ligaments for enterocele & prerectal fasciae and levator for rectocele with interrupted sutures is essential Excision of vagina should be tailor made
Perineorrhapy to be done only if perineal body is torn
Perineorrhaphy Not an Operation for prolapse, but Indicated only for associated old 2nd degree perineal tear Performed along with posterior colporrhaphy Aim-Reconstruction of the Perineal body and reduction of gaping introitus.
Essential steps - Excision of the scar tissue & approximation of levator ani & superficial perineal muscles
Vaginal Hysterectomy with/without Vaginal repair Indicated when uterus needs removal, in old age & in total prolapse. Patient’s consent is mandatory knowing that there are alternatives to hysterectomy. Usually combined with Ant. & Posterior colporrhaphy. Perineorrhaphy is not mandatory but case specific. Vault suspension is an essential step.
If sexual function is not needed narrowing of vaginal canal should be done.
Amputation of cervix Not for Prolapse.Indicated only for cervical elongation (Uterocervical length >12.5 Cm ) To be done only as a part of Fothergill’s repair/sling operations. Adequate cervical dilatation - a prerequisite Bladder displacement is a must Excision of cervix should not exceed 2 cm Likely to affect reproductive life
Long-term complications are real risks
Fothergill’s operation It is the operation of choice in uncomplicated Utero-vaginal prolapse when uterus is to be preserved but NO future child bearing is required. It is a combination of, Amp. of Cx., Fixation of the Meconrodt’s ligament to the anterior of Cx. & Ant. Colporrhaphy. D&C is a must. Post. Colporrhaphy to be performed only if Ent/Rectocele is present
Perineorrhaphy is usually not required
Fothergill’s operation Not useful if ligaments are weak & Uterus is of normal size. Purandare’s modification may help. Technically difficult operation, requiring high degree of surgical skill. Threat of short-term complications. Real possibilities of long term complications.
Sling operations are better alternatives
ABDOMINAL OPERATIONS FOR PROLAPSE
Closure or repair of enterocele
Abdominal Sling operations Indicated when the ligaments are extremely weak as in nullipara & young women. Preserves reproductive function. Principle - With a fascial strip / prosthetic material (Merselene tape or Dacron) the Cx is fixed to the abdominal wall / sacrum / pelvis. Amp.of Cx should also be done if Utereocervical length >12.5cm. Cystocele/Rectocele repair if needed can be done vaginally before or after.
Enterocele repair can also be done abdominally.
Abdominal Sling operations It is a major abdominal operation & Synthetic material is costly & not widely available in India. Shirodkar’s posterior sling. Purandare’s anterior cervicopexy.
Virkud’s composite sling.
Shirodkar’s sling Tape is fixed to the post. Aspect of isthmus & sacral promontory
Anatomically most correct but difficult to perform
Tape is anchored to the ant.aspect of isthmus and ant. abd. Wall
Virkud’s composite sling operation Tape is anchored from the post aspect of isthmus to sacral promontory on the Rt. side & ant. abd. Wall on the Lt. Side
Utrosacral ligament is plicated
Khanna’s sling operation Tape is anchored to ant aspect of isthmus & ant. sup. Iliac spine
Easier to perform and safer
Abdominal Colpopexy / Colposuspension Indicated when vault prolapse occurs after hysterectomy or vaginal laxity is to be corrected at abdominal hysterectomy. Major abdominal operation & technically difficult.
Sexual function is preserved.
Sacrocolpopexy Vault is fixed to 3rd & 4th sacral vertebrae with a facial strip / proline mesh under the peritoneum to the right of rectum
Enterocele repair can be done if required
Ant.Colpopexy Corrects ant. vag laxity & stress inc. Useful at abdominal hysterectomy / for vault prolapse. Extra peritoneal supra pubic approach if done alone. Enterocele repair i f required.
Vagina stitched to the i leo-pectineal ligaments.
Vault / Colposuspension
Vault is fixed to the abdominal wall by a facial strip or merseline tape
LAPAROSCOPIC SURGERY PROLAPSE Advantages of M I S -small incision, better view, haemostasis, no packing, minimal tissue & bowel handling, short recovery, less pain, insignificant scar Can all types of prolapse be treated?- Yes. Ant. / Post. Lower vaginal repairs if needed can also be done vaginally before or after lap.Surgery However extended period of rest is essential Presently cannot be widely practised
This is the surgery of the future today
LAPAROSCOPIC SURGERY PROLAPSE Cervicopexy / Sling operations with/without Lap.Paravaginal repair / Vaginal repair VH / LAVH / LH / TLH + Colposuspension VH / LAVH /LH/TLH+ Lap.Pelvic reconstruction Rectocele repair & levatorplasty
Enterocele repair with suturing of uterosacral ligaments
Laparoscopic Cervicopexy/sling Operations All types of sling operations can be better performed by laparoscopy Associated vaginal prolapse can also be repaired laparoscopically (Lap.Paravaginal repair)
Vaginal Ant./Post. colporrhaphy can be done before / after laparoscopy
Laparoscopic Vault suspension/ Culdoplasty)
Can be done with VH / LAVH / LH / TLH
Laparoscopic Pelvic Reconstruction With VH / LAVH / LH / TLH An alternative to Ward- Mayo’s operation Before Hys., Lap.Ureteral dissection is done and suture placed in uterosacral ligament near sacrum & left long, for latter vaginal vault suspension Lap. levator plication if needed Enterocele repair and suturing of uterosacral ligaments if needed
Retro pubic Colposuspension (Bruch) if required
Laparoscopic Rectocele repair & Levatoroplasty Rectovaginal space is opened & rectum dissected Interrupted sutures given in the levator in the midline Enterocele repair done if indicated
Vaginal vault suspension done
Laparoscopic Enterocele repair Rectovaginal space is opened, sac excised and purse string suture given
Uterosacral ligament sutured
Laparoscopic Post Colpopexy / Sacrocolpopexy Indicated for vault prolapse Enterocele if present is first repaired
Prolene mesh is fixed to the vault & 3rd-4th sacral vertebrae, under the peritoneum in the R t. p ara rectal space
Time has come for Laparoscopic Surgery for Prolapse So move with the times. Practice laparoscopy. This is the Surgery of the future today. THANK YOU